time when we don't know what the bill costs and we don't know what the employer mandates are and we don't know what the do. we'll get language up here that actually has the numbers on it. we can't run the numbers until we craft the language and give them something. >> they've run the numbers and it's a trillion dollars and

one-third -- >> we're in unprecedented waters with health care and a lot of the things we're talking about, getting numbers are difficult for cbo and they're under pressure from the house, the finance committee and others to produce numbers on various ideas that we might find commonality with, but it's a chicken egg argument in a sense. you can't get cbo numbers unless you have language. it makes the question one that people raise and that is the obvious one. if i can't answer that question then obviously -- you put on language and you can't run the numbers. we're trying to accommodate that and simultaneously recognize that despite the committee rules of 24 hours or so in a normal process of the bill, that's very difficult to do, so i want to accommodate members as senator byrd has raised to give adequate time next week for people to respond, john, to whatever the product is we put out so you can have amendments ready if you're not happy with the product that

we put out with the cbo numbers that have been provided. >> let me just add with the comment, even with the 12:00 accommodation, i can't get here. the airline schedule, i have no effect over, and i've been cut out. i understand we can't all make it, but let me just make this plea. if the legislation is not released to us today or at some point over the weekend where we can actually read it, i'm not sure that having the o come in and brief us on how they scored a product that we have yet to look at and disseminate the information is valuable to those of us who have not seen it. so if, in fact, we don't have the legislation before monday, i would ask the chair delay the cbo briefing until we've had an opportunity to review the legislation and better understand what cbo would then describe us to. >> thank you. >> mr. chairman, mr. chairman, i know you're trying to run a fair process and this is a very difficult job for you and you've

been brought into this in an extraordinary way, but let me tell you without question, the most important part of this bill and the guts of this bill is going to be coverage, and that's going to take days. under any circumstances, and that's where we're going to have to really work together if we have a bill at all, and yet, i think senator mccain's raised some very, very important issues here. we don't have the scoring. we have don't have the estimates on our side and i'll put it that way. it is very difficult to do if we don't have those. i know you know that. set the arbitrary deadlines when coverage is going to -- coverage on a bill like this takes a lot of time on any bill, but this is

one-sixth of the american economy. so all i can say is get us the information and let's not push this on so that we can't do a job that has to be done in order to not come up with a colossal mess here and i intend to work with him and see what we can do. coverage is not only important, it's probably the most controversial part of this and right now we don't have a way of understanding what coverage is and how you're going to handle it or how cbo, what their recommendations are as well and as senator mccain has said we have yet to see the language of this bl or all of the language of this bill especially the coverage part, and there are a lot of controversial amendments that by necessity have to be brought up. we haven't even seen language for the so-called government plan or employer mandates or

employee mandates that may be in this bill. so all i can say is i acknowledge your time to run a fair process. i hope to cooperate with you and to help you, but i don't see how you can set arbitrary deadlines by the end of next week. i mean, to even cover even a decent part of the coverage aspects and that's what's got me upset, and i don't think we should push things so hard that we don't do a decent job on this. >> that's our intention. i appreciate the comments. senator casey? >> let me just add a couple of comments here. this is a difficult process and those who have been here longer than i have know how difficult probably more than i have a full appreciation for. today and yesterday we're still on inequality, is that correct? >> that's correct. >> we're doing quality today. we're nowhere near getting to coverage. we're a ways from that. i understand the concern about

having -- having information. we're not on coverage yet. we're still on quality andtill a lot of work to do on this, but i know one thing, the american people want us to move. they don't want us to delay. they don't want us to slow down. they want us to move and get something done here. so i realize it's difficult, and i realize people want more information, but if we're still on quality today we can make progress on quality, but the last thing they want us to do is to sit back and to slow down. they want us to get this done as fast as we can&, and i think we're making progress on quality and we ought to make progress on quality when we get there. we should get something done. it's friday, and i think we can make progress this morning. >> let me say to my colleague from pennsylvania, i'm going to work with the chair any work

with the majority, but i think the american people want us to get it right. i don't think they want us to get anything. they want us to get it right, and as i said to the chairman early in the opening statements, we all ought to remember that what we do we get one shot at, and i want to work with the chair. i want to work with everybody on this committee to make sure that end of day we can be proud of the product. if we accomplish that by friday, great. if we don't, we'll know we had a healthy debate that was good for the process, at the end of day nobody knows what the product will be. at least i don't think that's the case. >> let's get to work on quality. that's what we're here to do. >> let me turn, if i can to senator murkowski and let's take time on so we can reach an agreement on. do you have the minutes? by the way, we have a quorum of 12 here and we have nominees.

so our committee -- let us go into executive session if i can for a few moments with my colleagues here to return to the affordable health choices act in a moment. kathy martinez is the nominee for the assistant secretary for disability employment, pol southeast department of labor. kathy greenlee is the nominee for assistant secretary of the department of aging. i want to thank chairman kennedy and ranking member mike enzi for their work on the nominations. i recognize mr. enzi. >> i have comments and it's been cleared on our side. >> all those in favor of the nominee say ayes. the nominees are confirmed by the committee and we report it accordingly. let me go back to senator murkowski until the amendments have been cleared. >> thank you, mr. chairman. i want to just say to the committee we had a good day yesterday. we accepted 17 amendments, and

very few from their side, but as the other side of the aisle offered suggestions and we can either accept them because they did approve the bill. senator enzi, comparative effectiveness were very constructive and we voted on two of them. i believe we can finish quality today or certainly finish quality on monday. let me get to what we could accept overnight. i have four amendments that we can accept. number one, we can accept murkowski number 9 which adds physician assistant to providers who may be part of a community health team. we can accept 9 which makes an excellent ak mendment and hatch 21 as modified and we agreed upon to add an iom stud we

hospital readmissions, and i think that, too, would add value to what our bill is. the other is we have 4 which goes to administrative i simplification which we can accept. i dare ask unanimous consent that murkowski 9, hatch 9, hatch 21 as modified and nc number 4 be accepted by unanimous consent. >> is there objection? >> mr. chairman, not an object, but i think there was an nc number 6 that went with nc number 4. nc number 6 was the easy one and nc number 4 was the more difficult. >> i was going to talk about nc 6. why don't we then, let's talk about nc 4. i withdraw my unanimous consent. i resubmitted to murkowski 9, hatch 9 and hatch 21 is

modified. i ask that it be adopted. you're saying it's murkowski 6. excuse me? i'm sorry, i can't quite read this note. i apologize. i again, withdraw my unanimous concept request. it's murkowski 6 that's the physician's assistants. hatch 9, hatch 21 as modified. i ask unanimous consent that there's three amendments be adopted. >> is there objection? without objection, no. i thank senator enzi. with the agreement on that, those amendments will be agreed to. >> i need to go to nc 4 and 6 on administrative simplification. i want to say to my good friend from wyoming that in consultation with the white

house on this because what nc 6 does is want to strike the word operations procedures in the administrative simplification, there is concern that if weism lement -- well, senator, you want to explain what the 4 and 6 are and then -- rather than me explaining what it is and what it is about it. >> thank you. yes, we certainly agree that we need to simplify the administration of health care and that that will make a huge difference, so i actually filed three amendments on this section. number five strikes a section because i didn't think it would work the way the authors intended, but i use number six to modify it so that i didn't need to do number five and that allows that at a minimum that do

no harm and the final amendment was amendment number four which replaces the underlying language with language that would simplify the administration of health care. so this number six is to make sure we do no harm any if there's still a word, there's something that's different there and we need to talk about that, but i think that six is important to keep the underlying provisions from backfiring and actually adding red tape and with the modifications, the underlying provisions might slow the process with the department of health and human services and if the language is enacted without my amendments and business operations would be interrupted and conversion costs could be astronomical. so i think cms has confirmed that this language that i'm trying to modify would throw a wrench in the works and so i was

just trying to come up with language that would make sure that we do no harm and then in amendment number four i have what i think is some additional simplification, and i'm pleased that that was recognized because there is some burdensome and time-consuming processes for updating standards relating to insurance claims, and if we facilitate quicker updates and implementations of the hippa transaction standards then we can make a huge difference and i do apply senator mikulski's intent for the simplification. i don't think it went quite as far as we can simplify it and make the changes. >> well, let me respond to the senator and usually on management and the administration, he and i tend to be often in sync because of this

considerable background in business and accounting and so on. however, in this one we have a respectful disagreement. the nc event number 6 has the operating rules on administrative simplification. i'm concerned that the enzi amendment would undermine efforts to reduce the administrative burden on health care providers both public and private by deleting the inclusion of operating rules.

hospitals to carry out administrative transaction and will reduce the administrative hassle in this area. the administration of health care kinds alone cost 410 to 14% of doctors practiced revenues. we estimate section 22 could save anywhere from 25 to $30 billion. now so that's what his amendment does. to be sure, though, i did consult with omb. i want to work with you, and we've had a good time working together. >> yes. >> they were concerned that by striking the requirements, the standards be unambiguous could likely lead to more variations

in which information is required and how it would be collected, et cetera and to the extent the greater variation undermines the very savings. so we want to decrease variations and we're concerned that the very intent of it -- instead would goa against the whole concept of administrative simplification, so i don't object -- this is not a volcanic objection here. >> well, we're very close on it and where my request came from that part is from cms so we ought to check with them, too because they said that they -- >> rather than voting you down, why don't we put you aside and let's make sure that everybody in terms of the white house team, both cms and omb have conferred and give us the best advice where we could have the best practices to achieve the

greatest savings, because the whole point of administrative sent riification is not an end into itself. it's not quality. quality is an end unto itself. administrative simplification is administrative procedure, and if we can iron out this, i'd be happy to do so. >> i agree. we're both talking about the same thing. cms seemed to have the operating rules in the same way and it turned out to be duplication. if that's the case we'd probably have it solved and so i would wait on that. >> hopefully we'll be able to zip through this on monday. let's go to something that we have to sift through which is roberts 1. in terms of roberts one, after our and it really -- if we go to

page 323 of the bill, section 2 219. the current language says that the center meaning will come, reports and recommendations shall not be construed as mandates for payment coverage or treatment. senator roberts in his amendment with strong concurrence with senator coburn suggested an alternative which says that the center would do is strike -- shall not be construed and insert the words are prohibited from being used. does that accurately reflect senator roberts? yes, ma'am. again, in consultation with those in the washington policy

department, they objected to that language, but they did not object to finding a middle ground. just stick with me a minute and let me finish the sentence. >> what washington policy department? cms? >> no. we're dealing with the white house policy. >> oh. >> who, in turn, deal with their agencies. could i go on to try to define a sensible center here which we just talked with your staff, but i don't think -- okay, the potential counteroffer which would say this, so the senator reports and recommendations are prohibited from being used as mandates for payment coverage or

treatments. yours is prohibited from being used for payment coverage or treatment. all we want to do is after prohibited from being used, insert the word as mandates. >> i thought that was sort of the plan. i was impressed on on. >> actually, i thought it even more finely tuned what you wanted because we instructed as we were going to have this conversation, pay attention to what the others were saying. there have been bonified arguments raised. of course, the need for outcomes research is widely accepted in most circles. so i could go on and tell you what their rationale was. their mandate and explicit means of regulatory policy. since congress and the

administration said policy, the original as well as the replacement language would make policymakers, policymakers subject to the prohibition on making senate reports or recommendations straight requirements for payment coverage or treatment decisions. your amendment would instead place the prohibition on all public and private health plans and not just policymakers. so we think the suggestion that i'm offering actually gets more to the heart of what you are saying which is really it keeps everybody out of the treatment room, and it also deals with the payment issue. this information could not be used in practice as well as policy which is a significant limitation when it's used since it a mys to doctors as well as health plans. as roberts proposes, doctors would not be allowed to use

senate reports or recommendations and treatment decisions even if they were good idea and we're willing to that. so we want to go to doctors about who is in charge of the room. our language would make it very clear that it is the doctor who is in charge. your language could prohibit the doctors from actually using solid information that could come out of this outcome. >> what i've done here, by the way, i put in front of each of you here the bill language as it is. the roberts/coburn proposal and the counteroffer so everyone can see the language in front of you now that's being distributed to you. >> mr. chairman? >> yes? >> senator mikulski, have you finished, ma'am? >> senator roberts? >> well, thank you, senator

mikulski, thank you for your willingness to work with us and thanks to the staff to try to get some -- some kind of understanding about this where we could agree on it. i think we have -- if you have counter language, i think we have counter-counter language, but we'll see where we go. i'm not concerned and, i can't speak to doctor coburn, but i think he would agree about the center being prohibited from mandating. my concern is prohibiting the cms from using information to mandate doctors' decisions and treatment, and if i might, a mandate is not the same thing as a prohibition. a mandate means to force or

bond. the language on page 323 are says that the reports and the center for health outcomes research and evaluate lgz which we'll be conducted the needed. comparative, effectiveness ask research and you can't inform doctors. that mandate says it does not preclude coverage and treatment. you have the other language -- >> on the bottom. the very last line. >> senator, reports and recommendations are prohibited from being used as mandates for payment, coverage or treatment decision. as i indicated, mandates is not the same thing as prohibit. this language, with all due respect, i do not think will prohibit cms from using this language for payments, coverage

or treatment. i don't think any of us really supports allowing cms to use information in this way. i know that i do not, and i know the distinguished doctor does not. cms, and i went into it into a long -- probably way too long remarks indicating we have a long track record of misusing date to deny patients access to new treatments, and i gave the example of the former head of cms and actually coming to my office since i had a hold on him, and he actually talked to a great many providers and cleaned up a letter that we sent, and i thought we got along fine and then within months cms was doing precisely the opposite of what he indicated. and then later when we had a

chance to visit on an airplane, why i let him know about that, and he expressed shock and amazement. so i think we really have to take that extra step of using the word prohibit. i just think we should have a flat prohibition that cms would not be allowed to set information for payment, coverage and treatment. that doesn't mean they can't inform and disseminate. after all, that's exactly what we want them to do to better educate and to better help doctors across the country. let me just repeat that -- in terms of controlling costs and cer. peter orszag who is very influential on this administration has said they will use cer to control dofts. larry summers has said they will

use cer to control costs. raymond kingston said it. he's the director out at nih, and i know the distinguished senator knows him personally, kathleen sebelius said it on his secretary of health and human services, and a personal friend of mine. he even -- he'd heard that the president's dog bo actually tuesday. >> well, he barked, but he said in case you didn't follow cms, there would be a biting consequence. i don't want to quarrel and get down into the weeks to the degree that we just tie up our efforts for the whole morning especially since it's a friday, and i do want to thank the chairman for his perseverance again and also the ranking member, and i do want to thank again senator mikulski who

always works with everybody with good intent. we have a counter counter, if i can find it. allison, do you have that or do i have that? >> if we want cms to inform and disseminate what they're about that we say now senator, reports and recommendations are prohibited from being used by any government entity for payment coverage or treatment decisions and we thought that that would be more precise. so i still believe that the word prohibit certainly is the intent of what we're trying to